Provider Demographics
NPI:1174017503
Name:LEWIS, KATHRYN JEAN
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:JEAN
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5478 S 31ST ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-9365
Mailing Address - Country:US
Mailing Address - Phone:616-890-3292
Mailing Address - Fax:
Practice Address - Street 1:5985 W MAIN ST STE 816
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-8721
Practice Address - Country:US
Practice Address - Phone:616-286-9598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-19
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008365103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist